Nursing Professional Development Program: 2015/2016

Forms List

Form Identifier / Form Title / Page Number
Form A / Applicant Information / 2
Form B / Manager Approval / 3
Form C / Research Project Documentation / 4
Form D / Evidence Based Practice Project Documentation / 5
Form E / Quality Improvement Project Documentation / 6
Form F / Journal Club / 7
Form G / Conference Poster Presentation / 8
Form H / Conference Podium Presentation / 9
Form I / Primary/Secondary Grant Writer / 10
Form J / Enrolled in a BSN, MSN or DNP program / 11
Form K / MSN/DNP Credential / 12
Form L / Professional Nursing Organization Membership / 13
Form M / Professional Nursing Certification / 14
Form N / Publications / 15
Form O / Professional Award or Recognition / 16
Form P / Community Service Activity Participation / 17
Form Q / Community Service Activity Management / 18
Form R / Credentialed Medical Interpreter / 19
Form S / Teaching Classes with the Education Department / 20
Form T / Competency/Skills Validator / 21
Form U / Unit Councils / 22
Form V / Champion/SuperUsers / 23
Form W / E Learning Module Development / 24
Form X / Case Presentation / 25
Form Y / Skill Certifications (Non job requirement) / 26
Form Z / Instructor Status for KOH taught courses / 27
Form AA / CE Program Development / 28
Form BB / Patient Education Presentation / 29
Form CC / KOH Nursing Award / 30
Form DD / Professional Nursing Organization Officer or Committee Chairperson / 31
Form EE / KOH Division or Facility Committee / 32
Form FF / Increasing Patient Experience / 33
Form GG / Preceptor / 34
Form HH / Health Lifestyle and Work Environment / 35

Form A: Applicant Information

Name: ______

Last First Middle

Address: ______

Street

______

City State Zip

Work Email Address: ______

Phone: ______͏ Home ͏ Cell

Facility:______Employee ID number: ______

Unit Name: ______Unit Cost Center: ______Manager: ______

Highest Level of Nursing Education Completed: ͏ ADN/Diploma ͏ BSN ͏ MSN

Professional Certification (if applicable): ______

Certification and Certifying Organization

Nursing Professional Development Program Level: Check level of application

Clinical Professional Nurse:
Level 1 / ·  Minimum1 year experience with KOH
·  Completed Orientation
·  BSN OR
·  ADN/Diploma enrolled in BSN program OR
·  ADN/ Diploma w/5 years of experience and certified in clinical specialty
·  Score of “Meets Expectations” on current evaluation
·  Evidence of 8 points
Clinical Nurse Leader:
Level 2 / ·  Minimum 2 years of staff RN experience
·  Minimum of 6 months with KOH
·  Completed Orientation
·  BSN required
·  Score of “Meets Expectations” on current evaluation
·  Evidence of 11 points
Clinical Nurse Expert:
Level 3 / ·  Minimum 3 years of staff RN experience
·  Minimum of 6 months with KOH
·  Completed Orientation
·  BSN required
·  Professional Certification in Clinical Specialty
·  Score of “Meets Expectations” on current evaluation
·  Evidence of 13 points

Attach: Recent Picture

Form B: Manager Approval

Manager Name: ______

Facility: ______Unit: ______

I recommend ______as an applicant to the Kentucky One Health Nursing Professional Development Program.

Comments:

______

______

Manager Signature Date

Verification at time of Portfolio Submission: All of the above information is still correct.

______

Manager Initials Date

Form C:

Research Project Documentation

Name: ______Employee ID #: ______

Research Project Title:

______

Indicate your role in the project: ͏ Principle Investigator ͏ Co-Investigator

Type of research: ͏ Quantitative ͏ Quantitative ͏ Other

IRB approval: Name of IRB: ______IRB #: ______

Study Contributions: What specific work have you done on the project—i.e. literature review, data collection, IRB submission, subject recruitment, etc.

Date / Description of Activity / Hours

______

Principle Investigator Signature Principle Investigator Name PRINTED

______

Date

Form D

Evidence Based Practice Project Documentation

Name: ______Employee ID #: ______

Evidence Based Practice Project Title: ______

______

What was the identified problem or opportunity: ______

______

PICOT question: ______

______

Type of project: ͏ Group Project ͏ Individual Project

If a group project, describe the applicant’s role in the project: (Examples conducted the literature review and analysis, collected the data, did the teaching, etc)______

______

______

EBP Practice Model Used: ͏ Iowa ͏ Johns Hopkins ͏ CHI ͏ Other

Literature Review: Please attach the literature review with a minimum of 5 recent references.

Describe the evidence based intervention: ______

______

______

______

Data/Outcomes: ______

______

______

Evaluation of the Project: ______

______

______

Manager/Project Sponsor Signature Manager/ Project Sponsor Name PRINTED

______

Date

Form E

Quality Improvement Project Documentation

Name: ______Employee ID #: ______

Quality Improvement Project Title: ______

______

What was the identified problem or opportunity: ______

______

Goal of the project: ______

______

Type of project: ͏ Group Project ͏ Individual Project

If a group project, describe the applicant’s role in the project: (Examples conducted the literature review and analysis, collected the data, did the teaching, etc)______

______

______

Change Model Used: ͏ PDCA ͏ Lewin ͏͏ Other

Describe the quality improvement intervention: ______

______

______

Data/Outcomes: ______

______

______

Evaluation of the Project: ______

______

Implications for Practice: ______

______

______

Manager/Project Sponsor Signature Manager/ Project Sponsor Name PRINTED

______

Date

Form F

Participation in an Approved KentuckyOne Health Journal Club

Facility: ______

Unit: ______

Chairperson/Leader: ______

Number of Journal Club meetings in the 12 months prior to portfolio completion: _____

Attach: One article review and critique presentation

I attest that the applicant ______has attended at least four journal club meetings in the previous 12 month period. Appropriate rosters or minutes verifying attendance can be provided if requested.

______

Manager/Chairperson Signature Manager/ Chairperson Sponsor Name PRINTED

______

Date

Form G

Conference Poster Presentation

Name of Conference: ______

______

Sponsor of Conference: ______

______

͏ Local/Regional ͏ National

Location of Conference: ______

Date of Conference: ______

Title of Poster Presentation: ______

______

Attach: Program agenda from conference listing poster and/or poster abstract

Attach: Poster (if possible) either picture of actual poster or Adobe computer copy

Form H

Conference Podium Presentation

Name of Conference: ______

______

Sponsor of Conference: ______

______

͏ Local/Regional ͏ National

Location of Conference: ______

Date of Conference: ______

Title of Presentation: ______

______

Length of Presentation: ______

Attach: Program agenda from conference listing presentation

Attach: Abstract for presentation

Form I

Primary/Secondary Grant Writer

Name of Grant: ______

Date of Grant application: ______

Project that the grant will support: ______

______

Was application successful? ______

͏ Primary writer ͏ Secondary writer

Attach: Verification page from grant application listing applicant as either primary or secondary grant investigator

Form J

Enrolled in a BSN, MSN or DNP Program

Name of Academic Institution: ______

Program of Study: ͏ BSN ͏ MSN ͏ DNP

Anticipated graduation date: ______

Attach: Current and most up to date transcript

Form K

MSN Credential/DNP Credential

Name of Academic Institution: ______

Course attendance years: ______

Course of study: ͏ MSN ͏ DNP

Date of graduation: ______

Attach: Transcript showing degree completion and/or copy of diploma

Form L

Membership in a Professional Nursing Organization

Name of Professional Organization:

1.  ______

2.  ______

Attach: Copy of membership wallet card or certificate with expiration date.

Form M

Professional Nursing Certification

Current area of clinical practice: ______

Certification1:

A.  Credential: ______

B.  Certifying Body: ______

C.  Expiration: ______

Certification 2:

A.  Credential: ______

B.  Certifying Body: ______

C.  Expiration: ______

Attach: Copy of certification wallet card or active certification credential with expiration date.

Notes:

Ø  One certification must be applicable to current area of practice

Ø  Certifications must be considered reimbursable as an eligible certification in KentuckyOne policy

Ø  Professional certifications DO NOT include: AHA programs (ACLS/BLS/PALS) or other job required certifications such as NRP, STABLE or TNCC

Ø  If you have questions regarding the eligibility of a particular certification for the NPDP, please consult with a board member or an educator

Ø  Complete list of certifications is available at: http://insidekentuckyonehealth.org/Nursing/Professional-Development

Form N

Publications

Professional Nursing Publication: (Article) ͏ Regional ͏ National

Name of Nursing Journal: ______

Date of Publication: ______

͏ Primary Author ͏ One of group author

Professional Nursing Publication: (Article) ͏ Regional ͏ National

Name of Nursing Journal: ______

Date of Publication: ______

͏ Primary Author ͏ One of group author

Professional Nursing Publication: (Book Chapter)

Name of Nursing Book: ______

Title or Number of Chapter: ______

Date of Publication: ______

͏ Primary Author ͏ One of group author

Professional Nursing Publication: (Book)

Name of Nursing Book: ______

Title or Number of Chapter: ______

Date of Publication: ______

͏ Primary Author ͏ One of group author

Attach: (Article) Copy of the article with identifying journal information

Attach: (Book) Complete reference information in APA format

Form O

Professional Award or Recognition

Title of Award or Recognition: ______

______

Award Organization: ______

Date: ______

͏ Local/Regional ͏ National

Title of Award or Recognition: ______

______

Award Organization: ______

Date: ______

͏ Local/Regional ͏ National

Attach: Copy of written professional award or recognition

Form P

Participation in a Community Service Activity

Title of community service activity: ______

Name of organization:

______

Description of community service: ______

______

______

______

Date of Community Service: ______Hours worked: ______

______

Signature of Project Coordinator/Facilitator Name of Project Coordinator/Facilitator (Printed)

______

Date

Note: fundraisers, such as walks do not qualify in this category

Form Q

Development/Management of a Community Service Activity

Title of community service activity: ______

Name of organization:

______

Description of community service: ______

______

______

Describe your role in development/management of the community service activity:

______

______

Date of Community Service: ______Hours worked: ______

______

Signature of Project Coordinator/Facilitator Name of Project Coordinator/Facilitator (Printed)

______

Date

Note: fundraisers, such as walks do not qualify in this category

Form R

Credentialed Medical Interpreter

Language: ______

Attach: Certificate of completion of a formal medical interpreter training

Form S

Teaching Classes

Class Name: ______

Hours of Instruction: ______

Date/Time of Class: ______

CE Information (if applicable):

Ø  CE number: ______# of CEs offered: ______

Ø  CE provider: ______

______

Signature of Education Representative Name of Education Representative (Printed)

______

Date

Class Name: ______

Hours of Instruction: ______

Date/Time of Class: ______

CE Information (if applicable):

Ø  CE number: ______# of CEs offered: ______

Ø  CE provider: ______

______

Signature of Education Representative Name of Education Representative (Printed)

______

Date

Form T

Competency/Skills Validator

Facility: ______

Competency/Skill being validated / Date / Hours / Points

______

Signature of Education Representative Name of Education Representative (Printed)

______

Date

Note: 1 point is given for each 4 hours of competency or skill validation up to a maximum of 2 points.

Form U

Unit Councils

Facility: ______Unit: ______

Name of Council: ______

Select one option: ͏ Chairperson/Co-Chairperson ͏ Participant/Member

Purpose of the Council: ______

______

How often does the council meet? ______

Applicant’s contributions to council activity: ______

______

______

______

I attest that the applicant ______has attended 75% of the council meetings in the previous 12 month period. Appropriate rosters or minutes verifying attendance can be provided if requested.

______

Manager/Chairperson Signature Manager/ Chairperson Sponsor Name PRINTED

______

Date

Form V

Champions/SuperUsers

Facility: ______Unit: ______

Champion or Superuser Project: ______

Purpose of Champion or SuperUser Designation: ______

______

______

Length of time in role: ______

I attest that the applicant ______has met the expectations of champion/superuser for ______at least a 6 month period.

______

Manager/Chairperson Signature Manager/ Chairperson Sponsor Name PRINTED

______

Date

Attach: One example of how you, as a champion/superuser, provided support to staff for the identified project. Include: your training responsibilities, dissemination of information, check off, etc. as appropriate.

Form W

E Learning Module

Facility: ______

Title of LEARN module: ______

Purpose of LEARN module: ______

______

Distribution group: ______

CE information (if applicable):

Ø  CE number: ______# of CEs offered: ______

Ø  CE provider: ______

______

Learn Administrator/Education Director Signature Learn Administrator/Education Director Name PRINTED

______

Date

Form X

Case Presentation

Facility: ______Unit: ______

Case Presentation Topic: ______

Date of Presentation: ______

Why was this case chosen for presentation: ______

______

______

Reference List: (Identify at least 3 references used to prepare for presentation

1.  ______

2.  ______

3.  ______

Information Dissemination Method: ͏ Staff Meeting ͏ In-Service

͏ Poster ͏ LEARN module ͏ Other ______

______

Manager Signature Manager Name PRINTED

______

Date

Attach: Learning objectives, handouts, evaluation summation

Form Y

Skill Certifications (Non job requirement)

Facility: ______

Unit: ______

Certification being used for this skill point:

1.  ______

2.  ______

I attest that the certification listed above is not a job requirement on ______unit.

______

Manager/Chairperson Signature Manager/ Chairperson Sponsor Name PRINTED

______

Date

Attach: Copy of certification wallet card or active certification credential with expiration date.

Note: examples of this type of certification are: ACLS, PALS, NRP, Stroke, etc.

Form Z

Instructor Status

Facility: ______

Course for which you are an instructor:

1.  ______

2.  ______

I have fulfilled my minimum instructor obligations as required by the individual course and facility policy: ͏ Yes ͏ No

Number of Courses taught within the last year: